Philadelphia is more dangerous than New Orleans

Philadelphia warns

The Spanish flu killed at least 20 million people worldwide between 1918 and 1923, and over 700 million people fell ill. The pandemic probably started in the US state of Kansas, even if its name still refers to the first report from Spain, possibly from February 1918, from the seaside resort of San Sebastián on the north coast of Spain.

The actual starting point was different, the Haskell County region of Kansas. At the beginning of the year, a country doctor had treated numerous patients with extremely severe flu symptoms. He noticed a rapid and sometimes fatal course of the disease. At least three people from the area were drafted into the Funston US Army training camp in late February. A cook there fell ill with the flu on March 4th, and three weeks later there were 1,100 seriously ill people and 38 deaths in the camp. The soldiers also called the disease "knock-me-down fever".

Source of infection war

The respiratory disease spread from there throughout the midwest and southeastern states of the United States. Initially there were few complications in the form of pneumonia and hardly any deaths. By May 1918, however, the death rate rose unusually sharply. There are many reports in the literature about how the wave of contagion ran around the globe, including about military transports and ports, how the warring powers initially concealed or tried to ignore the disease.

The rapid deterioration in the condition of the sick was a typical feature of the Spanish flu. Sometimes only a few days or hours passed from the first symptoms to death. Despite the high number of victims worldwide, doctors and scientists could not understand for years what triggered the event. The Pfeiffer bacillus, a bacterium that had been detected in many sick people, turned out to be the wrong path. Even the lack of antibiotics and the generally poor living conditions could not explain the unusually high mortality in retrospect. In 1933, when looking at the flu, which occurs annually in domestic pigs, it was first recognized that the trigger was a virus.

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Decades later, the virus was completely reconstructed. A combination of several factors - including the surface protein hemagglutinin on the virus, but also a specific reaction of the patient's immune system - made the pathogen particularly dangerous. Given that the Spanish flu is suspected to originate directly from birds, virologists still see the risk that the so-called H5N1 bird flu virus could take the same route again with relatively few mutation steps.

What makes the Spanish flu interesting for today's events around the novel coronavirus are the health policy measures that were used, for example, in the USA to contain the wave of infection. These interventions are also used today, and some have become the norm for other infectious diseases, such as the duty of doctors to report every case.

Isolation measures were ordered in the USA in 1918: quarantine for households with sick people, closings of schools, churches, theaters and dance establishments. Private funerals and public gatherings were prohibited. In 2007 the journal Proceedings of the National Academy of Sciences of the United States of America (PNAS) published a study on the relationship between these measures and the intensity of the 1918 epidemic. The authors noted that the potential benefits of the "non-pharmaceutical measures" although it is supported by mathematical models, it has not yet been systematically investigated.

Quarantine works

Using data on 19 different types of health interventions in 17 US cities, the researchers tested the hypothesis that early application of multiple interventions coincided with reduced disease transmission. There was evidence of this: cities that shut down public life early on had 50 percent lower peak death rates than cities that did not. The former also had less steep curves in the number of infections. The comparison of the cities of Philadelphia and St. Louis is currently mentioned very often from the PNAS paper. In Philadelphia, the disease was initially dealt with laxly and even a street parade was held. On September 18, 1918, the health department started a campaign against public coughing, spitting and sneezing, three days later influenza was declared a reportable disease. On October 1, 635 cases of flu were reported to the health department, which from today's perspective seems a gross understatement. The doctors were already overwhelmed with the care of the sick and no longer reported. On October 3rd, the city closed churches, schools, theaters, billiard halls and the like. It was apparently too late for that: after a month, almost 11,000 people had died in the city.

In St. Louis, Philadelphia was seen as a cautionary example. The first cases occurred in the city in the state of Missouri on October 5 - and the quarantine was implemented as early as October 7. The differences in the number of deaths were striking. For every 100,000 heads in Philadelphia they peaked at 257 per week, in St. Louis only 31.

The PNAS results were not unexpected, also considering that few cities maintained the measures for more than six weeks in 1918. In addition, the scientists were able to see that none of the measures alone led to an easier course of the epidemic in 1918 and after.

The fields of research outlined here show that pandemics definitely require “post-processing”. Rigorous interference in the life of the population, the suspension of basic rights, must be well founded. Government action in this country often lacks evaluation, i.e. scientific support and evaluation. Without such transparency, trust in democracies cannot be saved.

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